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Asian Pacific Journal of Reproduction 2012; 1(4): 318-319
Contents lists available at ScienceDirect
Asian Pacific Journal of Reproduction
Journal homepage: www.elsevier.com/locate/apjr
Document heading
A ptotic kidney with multiple arteries, one from a common renal artery stem
*
Gokhan Tulunay, Isin Ureyen , Alper Karalok, Taner Turan, Nurettin Boran
Etlik Zubeyde Hanim Women’s Health Reseach and Teaching Hospital, Gynecologic Oncology Division, 06010, Kecioren, Ankara, Turkey
ARTICLE INFO
ABSTRACT
Article history:
Received 3 October 2012
Received in revised form 5 October 2012
Accepted 4 December 2012
Available online 20 December 2012
Anomalies of major retroperitoneal vascular structures have been showed up in many reports
so far. Here, a group of vascular anomalies of retroperitoneum were reported, all of which were
encountered during the staging surgery of a 65-year-old woman with endometrium carcinoma.
There was no vascular injury during the surgery associated with these vascular abnormalities.
Since they are met quite frequently, it is important for surgeons dealing with retroperitoneum to
be aware of the possible anomalies of vascular and renal structures in this region.
Keywords:
Renal artery
Renal vein
Vascular anomaly
1. Introduction
2. Case report
Anomalies of major retroperitoneal vascular structure are
not uncommon. With a prevalence of 13.6% to 30.2%, they
are mostly diagnosed either during surgery or by imaging
techniques since they are mostly asymptomatic[1-3]. Renal
vascular anomalies are responsible for more than half
of these anomalies[1]. In a study, simple renal anatomy
with a solitary artery and vein was present in 72% of
kidneys[4]. Renal venous anomalies are seen on the right
side more commonly, since renal arterial anomalies have a
predilection to left side[5,6].
Pelvic and paraaortic lymphadenectomy is an essential
part of staging surgery done for most gynecological
malignancies. Therefore, it is a necessity for a gynecologic
oncologist to have a command of the anatomy of the
retroperitoneum and to be aware of the high incidence of
vascular anomalies of this region. Otherwise, hazardous
complications such as nephrectomy and vascular injury
requiring blood transfusion are inevitable.
Here, we reported a group of anomalies of renal vessels,
some of which are seen rarely.
We described vascular anomalies of retroperitoneum
encountered during the surgery of a 65-year-old woman
with grade II endometrium carcinoma in November 2011.
Since the frozen section analysis of the hysterectomy
material revealed a tumor filling all the cavity and tumoral
invasion more than half of the myometrium, pelvic and
paraaortic lymph node dissection was performed. During
dissection of retroperitoneum, vascular and renal anomalies
were recognized (Figure 1). The findings are as follows: (i)
The right kidney was below the level than that it should be
(a ptotic kidney). (ii) There were three arteries, one for the
lower pole and two for the upper pole, supplying the right
kidney while two veins were draining it. (iii) One of the
arteries supplying the upper pole was a branch of an artery
originating from abdominal aorta at a level below inferior
mesenteric artery and giving branches to both kidneys by
ascending upwards. (iv) The artery supplying the lower
pole was originating from the right common iliac artery.
(v) Right ovarian vein was a tributary of right renal vein.
(vi) There were two renal veins on the right side; one in
the original place, the other one was anterior to it. (vii) All
three renal arteries on the right side were overpassing the
inferior vena cava (precaval renal arteries). (viii) There was
no abnormality in the left side except the unusual course of
the left renal artery, supplying the left kidney by ascending
upwards after originating from a common renal artery stem.
The left renal vein was single and coursing over the aorta as
expected. There was no vascular injury during the surgery
associated with these vascular abnormalities.
*Corresponding author: Isin Ureyen, Etlik Zubeyde Hanim Women’s Health Reseach
and Teaching Hospital, Gynecologic Oncology Division, Etlik Street, Post code: 06010,
Kecioren, Ankara, Turkey.
Tel: +90 312 3220180
Fax: +90 312 3238191
E-mail: isin.ureyen@gmail.com
Gokhan Tulunay et al./Asian Pacific Journal of Reproduction (2012)318-319
The final pathological finding was stage IB grade
2 endometrioid adenocarcinoma. All removed 91
retroperitoneal lymph nodes, 39 of which were dissected
from paraaortic region, were pathologically free of disease.
Therefore, it is not erroneous to say that the vascular
anomalies mentioned above did not interfere with the
adequacy of the surgery.
319
of cases[7,8]. Although multiple renal vessels are usually
asymptomatic, they may cause hydronephrosis, hematuria
and asymptomatic proteinuria[8].
A special risk associated with multiple renal vessels is
the ligation of accessory renal arteries, because these are
end arteries and ligation of these arteries may cause partial
ischemia, renal function loss, and renal hypertension[2,3].
In a study by Yeh et al., 35% of precaval right renal
arteries arose from the anterior aspect of aorta, while 6%
of these arteries arose from right common iliac artery[9]. In
our case, one of the renal arteries arose from anterior aspect
of aorta, one arose from the common renal artery stem
originating from left side of the aorta, and one arose from
right common iliac artery.
In our case, the right ovarian vein was a tributary of right
renal vein in spite of the vena cava. This is a rare anomaly
seen in 1.3% of population[3].
Although a common renal artery stem has been defined and
known for more than 130 years, it is an unusual vascular
anomaly of the retroperitoneal region as can be seen in the
literature[10]. To our knowledge, this is the first case in which
such an anomaly was showed up during surgery. If there
had been any injury to this common artery, there would be
ischemia in both kidneys.
It is important for surgeons dealing with retroperitoneum
to be aware of the possible anomalies of vascular and renal
structures in this region, since they may cause serious
complications if the attention they deserve is not given.
Conflict of interest statement
We declare we have no conflict of interest.
References
Figure 1. Anomaly of major retroperitoneal vascular structure.
K: Kidney; VCI: Vena cava inferior; ARRV: Anterior right renal vein;
SRRA: Superior right renal artery; MRRA: Middle right renal artery;
IRRA: Inferior right renal artery; CS: Common stem; LRA: Left renal
artery; IMA: Inferior mesenteric artery. Written informed consent
was obtained from the patient for publication of this case report and
accompanying image.
3. Discussion
The vascular and renal anomalies of retroperitoneum
were reported in many researches and case reports. In the
literature, retroperitoneal vascular anomaly rates range
between 0.1% and 43% for veins and 9% and 31% for
arteries[2]. This abnormal vasculature is important because
of the possible increased injury to these vascular structures
during retroperitoneal surgery. It was shown to be important
to define these vascular anomalies in aorta-iliac surgery,
renal transplantation surgery and renal nephron-sparing
surgery preoperatively, while Kose et al. and Klemm et al,
reported that vascular injuries were not more common in
the cases with retroperitoneal vascular anomalies in a study
population composed of gynecologic oncology cases[1,2].
Multiple renal vessels are a part of these vascular
a nomalies. T hes e an om alies ar e d u e to v a ri o u s
developmental positions of kidneys and are seen more
frequently in the kidneys not ascended or rotated normally.
Multiple renal veins are shown to have a prevalence of 19%
and multiple renal arteries are found to be as high as 25%
[1] K
ose MF, Turan T, Karasu Y, Gundogdu B, Boran N, Tulunay
G. Anomalies of major retroperitoneal vascular structure. Int J
Gynecol Cancer 2011; 21(7): 1312-1319.
[2] K
lemm P, Fröber R, Köhler C, Schneider A. Vascular anomalies
in the paraaortic region diagnosed by laparoscopy in patients with
gynaecologic malignancies. Gynecol Oncol 2005; 96(2): 278-282.
[3] Benedetti-Panici P, Maneschi F, Scambia G, Greggi S, Mancuso
S. Anatomic abnormalities of the retroperitoneum encountered
during aortic and pelvic lymphadenectomy. Am J ObstetGynecol
1994; 170(1 Pt 1): 111-116.
[4] K
ok NF, Dols LF, Hunink MG, Alwayn IP, Tran KT, Weimar W,
et al. Complex vascular anatomy in live kidney donation: imaging
and consequences for clinical outcome. Transplantation 2008;
85(12): 1760-1765.
[5] Bordei P, Sapte E, Iliescu D. Double renal arteries originating
from the aorta. Surg Radiol Anat 2004; 26(6): 474-479.
[6] Janschek EC, Rothe AU, Hölzenbein TJ, Langer F, Brugger PC,
Pokorny H, et al. Anatomic basis of right renal vein extension for
cadaveric kidney transplantation. Urology 2004; 63(4): 660-664.
[7] Koc Z, Ulusan S, Oguzkurt L, Tokmak N. Venous variants and
anomalies on routine abdominal multi-detector row CT. Eur J
Radiol 2007; 61(2): 267-278.
[8] R
anade AV, Rai R, Prahbu LV, Mangala K, Nayak SR. Arched left
gonadal artery over the left renal vein associated with double left
renal artery. Singapore Med J 2007; 48(12): e332-334.
[9] Y eh BM, Coakley FV, Meng MV, Breiman RS, Stoller ML.
Precaval right renal arteries: prevalence and morphologic
associations at spiral CT. Radiology 2004; 230(2): 429-433.
[10]Macalister A. Multiple renal arteries. J Anat Physiol 1883; 17(Pt
2): 250-252.